| 1. |
- Annersten Gershater, Magdalena, et al.
(författare)
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Complexity of factors related to outcome of neuropathic and neuroischaemic/ischaemic diabetic foot ulcers: a cohort study
- 2009
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Ingår i: Diabetologia. - : Springer Science and Business Media LLC. - 1432-0428 .- 0012-186X. ; 52:3, s. 398-407
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Tidskriftsartikel (refereegranskat)abstract
- We sought to identify factors related to short-term outcome of foot ulcers in patients with diabetes treated in a multidisciplinary system until healing was achieved. Consecutively presenting patients with diabetes and worst foot ulcer (Wagner grade 1-5, below ankle) (n = 2,511) were prospectively followed and treated according to a standardised protocol until healing was achieved or until death. The number of patients lost to dropout was 31. The characteristics of the remaining 2,480 patients were: 1,465 men, age 68 +/- 15 years (range 18-96), type 1 diabetes 18%, type 2 diabetes 82% and insulin-treated 62%. The healing rate without major amputation in surviving patients was 90.6% (n = 1,867). Sixty-five per cent (n = 1,617) were healed primarily, 9% (n = 250) after minor amputation and 8% after major amputation; 17% (n = 420) died unhealed. Out of 2,060 surviving patients, 1,007 were neuroischaemic (48.8%). In a multiple regression analysis, primary healing was related to co-morbidity, duration of diabetes, extent of peripheral vascular disease and type of ulcer. In neuropathic ulcers, deep foot infection, site of ulcer and co-morbidity were related to amputation. Amputation in neuroischaemic ulcers was related to co-morbidity, peripheral vascular disease and type of ulcer. Age, sex, duration of diabetes, neuropathy, deformity and duration of ulcer or site of ulcer did not have an evident influence on probability of amputation. Patients with diabetic foot ulcer suffer from multi-organ disease. Factors related to outcome are correspondingly complex.
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| 2. |
- Apelqvist, Jan, et al.
(författare)
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Long-term prognosis for diabetic patients with foot ulcers
- 1993
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Ingår i: Journal of Internal Medicine. - 1365-2796. ; 233:6, s. 485-491
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE. To evaluate the recurrence of foot ulcers as well as the cumulative amputation and mortality rates in diabetic patients with previous foot ulcers. DESIGN. A prospective study of consecutively presenting diabetic patients admitted to the Department of Internal Medicine because of foot ulcer with a median follow-up of 4 years. SETTING. A multidisciplinary foot-care team. POPULATION. Five-hundred-and-fifty-eight consecutive diabetic patients with foot ulcers treated between 1 July 1983 and 31 December 1990 were followed to final outcome. Out of these patients, 468 healed either primarily (n = 345) or after minor or major amputations (n = 123) and 90 died before healing had occurred. Those 468 patients who healed were included in this prospective study from the time of healing. MAIN OUTCOME MEASURES. Patients were followed according to a standardized protocol with registration of foot lesions, amputation, morbidity and mortality. Clinical examination was performed twice yearly. RESULTS. After 1, 3 and 5 years of observation 34%, 61% and 70% of the patients, respectively, had developed a new foot ulcer. The recurrence rate of foot lesions was slightly higher among patients who previously had had an amputation (P < 0.05, P < 0.01 and non-significant, respectively). Among patients with previous primary healing the cumulative amputation rates were 3%, 10% and 12% after 1, 3 and 5 years of follow-up compared with 13%, 35% and 48% among those who previously healed after amputation, irrespective of previous amputation level (P < 0.001 at all time-points). All amputations except three were initiated by a foot ulcer deteriorating to deep infection or progressive gangrene. The long-term survival ratio was lower among patients healed after previous amputation (80%, 59%, 27%) compared with patients with previously primary healing (92%, 73%, 58%) after 1, 3 and 5 years of observation, respectively (P < 0.001, P < 0.01 and P < 0.001 respectively). The mortality rate was twice as high among primarily healed and four times as high among patients with amputation compared to an age- and sex-matched Swedish population. CONCLUSION. These findings stress the need for life-long surveillance of the diabetic foot at risk and the necessity of preventive foot care among diabetic patients with previous foot lesions, and particularly among those who had had a previous amputation.
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| 3. |
- Apelqvist, Jan, et al.
(författare)
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Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer
- 1989
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Ingår i: Diabetes Care. - : American Diabetes Association. - 1935-5548 .- 0149-5992. ; 12:6, s. 373-378
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Tidskriftsartikel (refereegranskat)abstract
- The prognostic value of distal blood pressure measurements has been studied in 314 consecutive diabetic patients with foot ulcers. Systolic toe blood pressure was measured with a strain-gauge technique, and ankle pressure was measured with strain-gauge or Doppler techniques. Wound healing was defined as intact skin for at least 6 mo. One hundred ninety-seven patients healed primarily, 77 had amputations, and 40 died before healing had occurred. In 294 of 300 patients, it was possible to measure either ankle or toe pressure. Fourteen patients were not available for pressure measurements. Of these, 10 patients healed primarily, and 4 died before healing occurred. Both ankle and toe pressures were higher (P less than .001) among patients who healed without amputation compared with those who underwent amputation or died before healing. No differences were seen in ankle or toe pressure levels among those who had amputations or died. No patient healed primarily with an ankle pressure less than 40 mmHg. An upper limit above which amputation was not required could not be defined. Primary healing was achieved in 139 of 164 patients (85%) with a toe pressure level greater than 45 mmHg, whereas 43 of 117 patients (36%; P less than .001) healed without amputation when toe pressure was less than or equal to 45 mmHg. In conclusion, a combination of ankle and toe pressure measurements is a useful tool to predict primary healing in diabetic foot ulcers.
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| 4. |
- Apelqvist, Jan, et al.
(författare)
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The importance of peripheral pulses, peripheral oedema and local pain for the outcome of diabetic foot ulcers
- 1990
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Ingår i: Diabetic Medicine. - 1464-5491. ; 7:7, s. 590-594
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Tidskriftsartikel (refereegranskat)abstract
- In a prospective study, peripheral pulses, claudication, peripheral oedema, and rest pain were evaluated in 314 sequentially presenting diabetic patients with foot ulcers. In the ulcerated limb pedal pulses were found to be present in 44% of the patients, peripheral oedema in 38%, and rest pain in 19%. Twelve per cent had claudication. Presence of pedal pulses was more common in patients whose ulcers underwent primary healing (56%) than in those who healed after amputation (23%) or died (25%, p less than 0.001). Eighty per cent of the patients with pedal pulses present underwent primary healing. However, 49% of patients with absence of pedal pulses also underwent primary healing and 12 patients developed gangrene despite presence of pedal pulses. Peripheral oedema was more common in patients who required amputation (58%) or died (55%) than in patients with primary healing (26%, p less than 0.001). A tentative predisposing factor was identified in 95% of the patients, the most common factors being neuropathy, congestive heart failure, and previous deep venous thrombosis. Rest pain was more common in patients who required amputation (48%) or died (23%) than in those with primary healing (7%; p less than 0.001). Only 50% of patients with gangrene had rest pain and of these patients, only one underwent primary healing. The presence of pedal pulses, oedema, and rest pain give valuable but imperfect information on the possible primary healing of foot ulcers in diabetic patients.
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| 5. |
- Apelqvist, Jan, et al.
(författare)
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Wound classification is more important than site of ulceration in the outcome of diabetic foot ulcers
- 1989
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Ingår i: Diabetic Medicine. - 1464-5491. ; 6:6, s. 526-530
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Tidskriftsartikel (refereegranskat)abstract
- The importance of wound classification and site of ulceration was evaluated in 314 consecutive diabetic patients with foot ulcers. The ulcers were classified as superficial (through the full thickness of the dermis; n = 150), deep (n = 50), osteomyelitis and/or abscess (n = 46), minor gangrene (n = 39) or major gangrene (n = 29). Wound healing was defined as intact skin for at least 6 months. In patients with superficial and deep ulcers, primary healing occurred in 88% and 78%, respectively, compared with 57% in those patient who developed an abscess and/or osteomyelitis. Only 2 out of 68 patients with gangrene healed (through mummification) without amputation. Patients with gangrene had lower ankle and toe blood pressure than patients with all other types of ulcers. There were only marginal differences in primary healing rate between different ulcer sites. The highest rate was seen in ulcers localized to the metatarsal heads (78%). Patients with multiple ulcers had the lowest primary healing rate (5%) compared with single ulcers at all sites. These differences were probably due to circulatory factors, since patients with multiple ulcers had lower distal perfusion pressures compared with all other groups.
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| 6. |
- Elgzyri, Targ, et al.
(författare)
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Early Revascularization after Admittance to a Diabetic Foot Center Affects the Healing Probability of Ischemic Foot Ulcer in Patients with Diabetes.
- 2014
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1532-2165 .- 1078-5884. ; 48:4, s. 440-446
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Tidskriftsartikel (refereegranskat)abstract
- There is limited information about whether time from recognition of decreased perfusion to revascularization affects the probability of healing in a patient with a diabetic foot ulcer. The aim of the present study was to examine whether time to revascularization after referral to a multidisciplinary foot center was related to the outcome of foot ulcers in patients with diabetes and severe peripheral arterial disease (PAD).
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| 7. |
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| 8. |
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| 9. |
- Larsson, J, et al.
(författare)
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Clinical characteristics in relation to final amputation level in diabetic patients with foot ulcers: a prospective study of healing below or above the ankle in 187 patients
- 1995
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Ingår i: Foot & Ankle International. - 1944-7876. ; 16:2, s. 69-74
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Tidskriftsartikel (refereegranskat)abstract
- The aim of this study was to describe the clinical characteristics in relation to final amputation level in diabetic patients with foot ulcers. In a prospective series, 187 consecutively presenting patients were investigated. From admission until final outcome, the patients were treated by a multidisciplinary team both as in- and out-patients. All the patients had one or more signs of neuropathy and 171 had evidence of peripheral vascular disease. Healing with an amputation below the ankle occurred in 74 patients, 88 patients healed with an amputation above the ankle, and 25 patients died unhealed. Amputation above the ankle was associated with high age, living in an institution, a limited walking capacity, cerebrovascular disease, congestive heart failure, and a low hemoglobin level. Amputation below the ankle was associated with diabetes diagnosis before 30 years of age and diabetes duration. In conclusion, older age, history of cerebrovascular disease and low hemoglobin level are associated with above ankle amputation level in diabetic patients with foot ulcers. However, level selection cannot be based upon these factors only, since some patients at high age, with cerebrovascular disease or with a low hemoglobin value, healed with an amputation below the ankle. None of these factors per se should be taken as a cause to choose a primary amputation above the ankle, unless amputation is supported by the total clinical picture, including local characteristics, such as type and localization of ulcer, and signs of peripheral vascular disease. More attention should be paid to biological than to chronological age.
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| 10. |
- Larsson, J, et al.
(författare)
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Decreasing incidence of major amputation in diabetic patients: a consequence of a multidisciplinary foot care team approach?
- 1995
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Ingår i: Diabetic Medicine. - 1464-5491. ; 12:9, s. 770-776
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Tidskriftsartikel (refereegranskat)abstract
- The purpose of this retrospective study was to evaluate the changes in diabetes-related lower extremity amputations following the implementation of a multidisciplinary programme for prevention and treatment of diabetic foot ulcers in a 0.2 million population with a 2.4% prevalence of diabetes. All diabetes-related primary amputations from toe to hip from 1 January 1982 to 31 December 1993 were included. In 294 diabetic patients, 387 primary major (above the ankle) or minor (through or below the ankle) amputations were performed, constituting 48% of all lower extremity amputations. The annual number of amputations at all levels decreased from 38 to 21, equalling a decrease of incidence from 19.1 to 9.4/100,000 inhabitants (p = 0.001). The incidence of major amputations decreased by 78% from 16/1 to 3.6/100,000 inhabitants (p < 0.001). The absolute number of amputations with a final level below the ankle showed no increase, but their proportion increased from 28 to 53% (p < 0.001) and the reamputation rate decreased from 36 to 22% (p < 0.05) between the first and last 3-year period. Thus, a substantial long-term decrease in the incidence of major amputations was seen as well as a decrease in the total incidence of amputations in diabetic patients. Seventy-one per cent of the amputations were precipitated by a foot ulcer. These findings indicate that a multidisciplinary approach plays an important role to reduce and maintain a low incidence of major amputations in diabetic patients.
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